CASE 1
CASE DISCUSSION
Case description: 64-year-old female presented requesting a routine dental examination, having not seen a dentist in 2 years. She was not aware of any oral mucosal problems, although on closer questioning did gave a 1-month history of mild discomfort when eating affecting her right palatal mucosa. She also gave a history of recurrent (albeit infrequent) oral ulcers for as long as she can remember, which do not normally bother her. Her medical history is significant for ovarian cancer managed with Caelyx (doxorubicin hydrochloride). She reported smoking 1-2 cigarettes per day but denied any significant alcohol use.
Activity:
- Identify the pathosis and describe the clinical features
- What is the differential diagnosis?
- What are the relevant clinical investigations?
- What is the diagnosis?
- How would you manage this patient?
1. Identify the pathosis and describe the clinical features
List of things :
- The patient presents with a complex array of oral lesions across different sites.
- Red Lesion: A deep, depressed ulcerated area.
- White Lesions: Multiple white patches (leukoplakia-like) located near the red lesion.
- Brown Lesions: Four distinct pigmented (brown) patches/macules.
How to answer in a test
Exam Strategy: Identifying Pathosis
To “identify the pathosis” in an exam setting, you must objectively describe every abnormality visible:
- Step 1: State the number and color of lesions (e.g., "I see four brown patches, one red ulcerated area, and multiple white patches").
- Step 2: Describe the morphology (e.g., "The red lesion is depressed/deep").
- Step 3: Note the location and distribution.
2. Differential Diagnosis
White lesions:
- Oral lichen planus
- Frictional keratosis
- Leukoplakia: A clinical term for a white patch that cannot be rubbed off or characterized as another disease; often associated with dysplasia.
- Chronic Hyperplastic Candidosis: A fungal infection that presents as a white patch that cannot be wiped off.
Red lesions:
-
Traumatic Ulcer: Often related to local irritation or injury.
-
Squamous Cell Carcinoma (SCC): Can frequently present as a persistent, deep ulcer.
-
Erythroplakia: A red patch that cannot be characterized clinically or pathologically as any other condition; high risk of malignancy.
-
Viral Infection: (e.g., Herpes Simplex or Herpes Zoster), though these typically present as multiple, irregular, more superficial ulcers rather than a single deep one.
Brown (Pigmented) Lesions
- Smoker’s Melanosis: Usually more generalized; less likely here as the patient only smokes 1–2 cigarettes per day.
- Drug-Induced Melanosis: Pigmentation caused by systemic medications.
- Melanotic Macule: Benign pigmented spots.
- Melanoma: Very rare in the oral cavity, but the palate is the most common site when it does occur.
3. Relevant investigations
The list of investigations is:
Terminology Note
In an exam, "Medical History" is not a clinical investigation. Investigations refer specifically to biopsies, blood tests, imaging, and swabs/smears.
- full blood count
- Iron studies
- biopsies
- Imaging (CT, OPG, Cone Beam CT)
- Swabs/Smears
Full blood count
- P/t is on Caelyz which can cause thrombocytopenia
- Doxorubicin (Caelyz) is a cytotoxic drug
- White Cell Count: Cytotoxic drugs can decrease white cell counts, increasing susceptibility to infection
- Platelets: Essential to check levels before invasive procedures to assess bleeding risk
Iron studies
- Folate
- B12
- ferritin
- Cumulative Iron Studies
Biopsy
- Procedure: Sample the red, white, and brown areas (especially the ulcer and white patches) to rule out malignancy
- Referral: If a clinician is not confident performing the biopsy, the patient must be referred to a specialist
Smear
- less invasive than a swab
- if you suspect candida then you’ll see hyphae
- Swab vs. Smear: A swab only shows if the organism is present (50% of population are carriers)
- Smear Technique: Scrape with a sterile tongue depressor, smear on slide, apply fixative
- Microscopic Findings: Presence of hyphae indicates an active infection rather than simple colonization
4. Diagnosis
Brown lesions:
- Melanotic macules
- caused by medication
White lesions:
- Leukoplakia (from epithelial dysplasia )
- Presence of dysplasia rules out simple frictional keratosis
Red lesion:
- From OSCC
- The deep, depressed nature of the ulcer and use of cytotoxic medication (Doxorubicin) points toward SCC risk
5. Management
Brown Lesions
- Benign don’t worry about it
- Drug induced melanotic macules
White Lesions
- Excise to stop furthering of epithelial dysplasia
Red Lesions
- since they are most likely OSCC we will refer the patient to a multidisciplinary team
Additional Lecturer comments
- History Taking: Consultations often last an hour; distinguish "History" from "Investigations" in assessments
- Imaging: OPG is often inappropriate for soft tissue unless bone involvement or dental trauma is suspected
- Clinical Records: Clinical photographs are considered "records," not "investigations"
- Medication Side Effects: Cytotoxic drugs like Doxorubicin are statistically associated with an increased risk of oral SCC
Audio Appendix
Additional Audio Content
The following sections from the lecture audio did not correspond to any heading in the main document.